Michael is a 56-year old male who presents with complaints of increasing upper abdominal pain over the last 4 weeks. He describes his pain as a burning sensation and localized in the epigastric region. He notes that when he has had this pain previously he was able to get it to subside by drinking milk, but this time that is not helping and neither is taking antacids. He rates his pain a “7” on a scale of 1-10. He denies
any radiation of the pain, nausea, vomiting, changes in appetite, or weight loss. He has a past medical history of hypertension, hyperlipidemia, and obesity. He takes lisinopril and atorvastatin daily . Symptoms and Medical History Abdominal Ultrasound Essay Paper
Given Michael’s symptoms and medical history, it is important to consider the possibility of several different conditions that could be causing his upper abdominal pain. One possibility is gastroesophageal reflux disease (GERD), which occurs when stomach acid flows back into the esophagus and causes irritation and inflammation. This can lead to symptoms such as heartburn, regurgitation, and a feeling of fullness in the upper abdomen. Milk and antacids can sometimes provide temporary relief for GERD symptoms, but in more severe cases, prescription medications such as proton pump inhibitors (PPIs) may be necessary to reduce stomach acid production and alleviate symptoms.
Another possibility is peptic ulcer disease (PUD), which is a condition where open sores develop in the lining of the stomach or small intestine. The burning sensation in the epigastric region that Michael is experiencing is a common symptom of PUD, and milk and antacids may provide temporary relief by neutralizing stomach acid. However, in some cases, PUD can lead to complications such as bleeding or perforation of the stomach or intestine, which require urgent medical attention.
Other potential causes of upper abdominal pain in a patient with Michael’s medical history include pancreatitis, gallstones, or even a heart attack.
It is important for Michael to undergo a thorough medical evaluation, including a physical examination, blood tests, and imaging studies such as an abdominal ultrasound or CT scan, to determine the underlying cause of his symptoms and develop an appropriate treatment plan. Symptoms and Medical History Abdominal Ultrasound Essay Paper